Background
Well into its second year, the worldwide COVID-19 pandemic continues to pose substantial challenges for health care access and delivery. Regulatory agencies such as the Centers for Disease Control (CDC) do not currently have guidance related to COVID-19 specific to sleep centers and laboratories. In March 2020, within days of the World Health Organization pandemic declaration, the American Academy of Sleep Medicine (AASM) posted detailed guidance on mitigation strategies for sleep medicine practices (COVID-19 Resources).
Dr. Shannon S. Sullivan
This initial guidance has been previously reported in this publication (Sullivan S, Gurubhagavatula I. CHEST Physician 2020 May 8), and the guidance has been periodically updated during the pandemic. It was restructured in mid-2020 to include sections summarizing CDC recommendations germane for sleep practices; additional sleep medicine-specific guidance from the AASM COVID-19 Task Force (TF); and a frequently asked questions (FAQ) section. The last major update from the task force occurred on Jan. 18, 2021, though subsequent posts – especially related to recent CDC changes in masking guidelines – were made in May 2021. The purpose of this article is to summarize these updates and to call attention to areas of ongoing interest to sleep medicine. Notably, the AASM Task Force guidance is nonbinding and offered as a framework for considering best practices in this evolving situation, acknowledging the importance of weighing local factors, conditions, and regulations, as well as the interests of and risks to the patient, staff, and providers.
Dr. Ian Lee
Key updates
Data on exposure and transmission risks specific to sleep medicine
Measures for reducing viral transmission have been central to managing the spread of the virus in clinical settings. In its last major update, the AASM TF noted that no known outbreaks of COVID-19 related to sleep center exposure have been reported. A perspective and data published in the Journal of the American Medical Association concluded that hospital transmission of the virus “in the setting of universal masking is likely rare, even during periods of high community prevalence.” It also concluded that hospital-based outbreaks are more likely to occur in small workrooms and during mealtime when staff are less adherent to masking and physical distancing (Richterman A, et al. JAMA. 2020;324[21]:2155-6). The TF elaborated on considerations to reduce transmission, which include not just telework and foundational infection control practices, but also broader workplace considerations such as optimizing ventilation, taking advantage of outdoor spaces (e.g., for breaks and eating), scheduling to reduce interactions between personnel from different teams, minimizing contact in meeting/break rooms, removing tables and chairs from lounge areas, and following CDC guidance for effective facility operations.
Vaccination
In the January update, the AASM COVID-19 TF stated that, “sleep facility leaders should encourage staff and patients to be vaccinated in accordance with CDC guidance.” The role of the sleep medicine community in encouraging healthy sleep habits before and after vaccination was emphasized, pointing to evidence linking sleep and immunity, specifically between sleep duration and vaccination response (Healthy sleep and immune response to COVID-19 vaccination. 2021 Jan.).
In an FAQ update from March 26, 2021, considering whether continued COVID-19 testing was needed following full vaccination, the AASM advised testing prior to potential aerosol-generating procedures should be made on the basis of a risk-benefit assessment by the sleep clinician. Several considerations were highlighted, including recent COVID-19 infection, vaccination status of contacts, local prevalence of newer variants, and whether individuals are receiving positive airway pressure therapy. The TF focused on the vigilance for residents and staff in long-term care facilities, which have been associated with a number of outbreaks.
Masking in the context of the COVID-19 vaccine
The most significant change in recommendations is the recent relaxation of masking guidance by the CDC in the setting of the approval and distribution of COVID-19 vaccinations. In May, the CDC stated that fully vaccinated individuals can resume activities without masking or physically distancing except in scenarios of travel and where required by laws, regulations, and local businesses, due to the efficacy of the vaccines, increasing evidence of reduced asymptomatic carriage and transmission after vaccination, and anticipated increased uptake of vaccination. However, the CDC also noted that these updates did not apply to health care facilities, where the recommendation remains that patients and visitors should continue to mask throughout their stay. Additionally, fully vaccinated health care workers should continue to practice infection control measures while working with patients. On May 14, the AASM TF provided a detailed FAQ acknowledging the CDC’s new guidance, emphasizing that masking guidance in health care facilities remains unchanged, and encouraging individuals to follow CDC guidance regarding vaccination, noting that emergence of newer variants continues to be monitored, and existing vaccines still appear to induce neutralizing antibodies even if to a somewhat lower degree. The situation for pediatric sleep centers has been highlighted in particular because the potential risk posed by newer variants to children remains under investigation, and children under age 12 are not approved for vaccination.
Important caveats to discussions around vaccination status are the lack of a centralized method to identify vaccinated individuals, the unknown duration of immunity, and reports of the use of fake vaccine cards. At this time, in health care settings, vaccination status should not exempt mask usage for any individual.
Sleep medicine care for those with COVID-19
Regarding the duration of isolation and precautions for adults with COVID-19, the TF highlighted the CDC’s symptom-based strategy, rather than test-based strategy, for ending isolation of these patients, availing them of sleep medicine services in person.
In line with the CDC guidance, this approach indicates that scheduling in-person care such as polysomnography for a COVID-19–positive patient may be appropriate at least 10 days after symptom onset (or after a positive test if the patient never developed symptoms); or at least 20 days after symptom onset if the illness was severe; or if at least 90 days have elapsed since symptom onset, consider preappointment COVID-19 screening. In the context of immunocompromised individuals, involvement from infectious disease specialists may be needed to help guide decisions.